Consultations & hearings on Quebec Bill 52

Bill 52

Bill 52 proposes to legalize euthanasia by physicians in Quebec.
Public hearings about the bill were held in September and October, 2013 by
the Committee on Health and Social Services of the Quebec National Assembly.

The College of Physicians

The
College of Physicians of Quebec
(Collège des médecins du Québec) is the state regulator of
the practice of medicine in Quebec, with disciplinary power over all Quebec
physicians. Its basic organization and powers are set out in the
province's Professional Code.
In a
"reflection" issued in October, 2009, the College expressed the view that
euthanasia can be an acceptable "medical act," consistent with the College's
Code of Ethics requirement. This contributed to the formation of Quebec's Select Committee on Dying
with Dignity. On 15 February, 2010 the Federation presented a
brief to the
Select Committee recommending legalization of the procedure.
Bill 52 is the response of the Quebec government to the
Select Committee Dying with Dignity Report.

The transcripts

Unrevised French versions of the presentations at the hearings are
available on the National Assembly website. It takes the Assembly two
to four months to produce a final French text.

The unrevised transcipts have been processed using Google Translate
to produce the following parallel French-English texts.

The Focused Parallel
Transcript appears first. It includes only parts of the hearing
transcript broadly relevant to the issue of freedom of conscience for health
care workers. It is a more refined translation of the corresponding
sections of the Full Parallel
Transcript, which is found below it.

The same translation block numbers (T#) are used in both the Focus and
Full Parallel Transcriptions.

. . .
this bill is, in
our view, a very important milestone
in thinking about life care,
and, in our
opinion, should be adopted.
. . . From the
outset, please allow
us to recognize the
outstanding work done
on this extremely complex and sensitive topic by
all parliamentarians, particularly
yours, Madam
Minister. You have
demonstrated rare qualities of respect, attentive
listening, rigor
and an understanding of the challenges,
and we sincerely thank you. It deserves to be
highlighted.

. . .
The College of Physicians readily
supports this bill, which is responsive to the vision we
initially proposed, namely: to address the
care of life as a
whole; to recognize
the patient's
legitimate right to express their wishes
about the care they
would like at the end of
life;. . . to put the question
euthanasia within the context of care, which
allows the introduction of a
relatively new concept, medical
help to die;
to define social and
medical criteria restricting
to exceptional situations
the use of this aid; to take into account
the need to protect the most
vulnerable people; to provide a control mechanism. . .
and ensure the continuation
of the debate, of which
this bill can
only be a step.

Concerning
the recognition of the role
of the patient and his or her
rights, the
bill's second objective is to recognize
the primacy of the clearly and freely expressed will of an individual
with respect to care, among others,
in advance directives. . . . Also,
it is important to point out
a first ambiguity.
Even when we are willing to
recognize the primacy of the
will, there are other
elements that are essential
for decision making in
clinical practice. . .
This is especially true
when it comes to
extreme and exceptional
care such as medical aid to
die . . .

a) . . . these provisions
require institutions to
provide for the supply of
end of life care
in plans for [delivery of] medical services.
The responsibility of institutions
for the management of requests
for medical assistance to die
seems to us a particularly interesting way to meet
both the demands
expressed by some patients,
the right to some doctors
to conscientious
objection and constraints
based on social
consensus. . . .

d) We understand that it is necessary to make
careful choices in order to respect the
social consensus carefully reached by the Special
Committee.
And the college welcomes the
wisdom of such an approach,
fortunately compensated for by
the possibility of further
discussion.

a)
Among the open questions,
note that the report of
the Special Committee on
Dying, in its Recommendation No. 24, encouraged the college to explore the possibility
that a person with
dementia caused by
degenerative brain disease
could make
an early application for
medical assistance to
die. It was hoped that a joint committee
of experts under the auspices
of the college would produce an opinion on this issue.

b) So it is with pleasure, Mr. President, I
enclose with our brief, which you have received,
the result of this study
conducted during the past
year by the Quebec Bar, the Quebec
Chamber of Notaries ,
the Order of Nurses in Quebec and the College of Social Workers and
Marriage and Family Therapists of Quebec, as well as several other
experts.

c) All these professional bodies, including the
College, have adopted this opinion, and we submit it for the rest of
your work, and possibly the work of the new commission created to
address unresolved issues.

It
also seems useful to
better clarify in this
section or elsewhere in the
bill, what is meant
by the medical assisted dying.
. . .this
term suits us because
it says it is
an act which is
done by a doctor in a
care setting, which excludes
physician-assisted suicide.
It remains
that this is an act of
intentionally causing
the death of a person,
but this,
in the context of end of life
care in exceptional
circumstances and under the
conditions established
by law.

Medical assisted dying
is not necessarily contrary
to medical ethics, but it should
remain an option of last
resort for exceptionally difficult
situations at the end of life. Among the
elements that justify
recourse to it,
we should, we believe, find
that the person is
not only the end of life,
but in the final
stages of a serious and incurable
disease that is inflicting refractory suffering.

Unfortunately, any
suggestion that
incompetent patients may benefit from
medical aid to die contributes to fear of abuse. While understanding
that the legislature must be
careful, we can,
we believe, imagine
alternatives other than completely closing
the door on incompetent
patients, other than those who made advance directives when they were
competent.

While
supporting the creation of
a regime based
on advance directives, we believe
that it remains appropriate
to designate an authorized representative
and must retain the practice of [consent by patient representative].

We
have had feedback from our
psychiatric colleagues where
there some mental illnesses
that could meet the
definition that is currently in
the bill, but death
is not necessarily imminent.
. . we wanted to
focus the issue of
physician-assisted dying
to exclude other pathologies
whose evolution is much
longer, but
that could lead to some
degradation and some
suffering, whether physical or
psychological.

Ms.
Marchand (Michele): . . .
What psychiatrists
have told us, is that there
are people for whom
death is inevitable and
imminent because they
have decided they wanted to die,
because they feel that their
life is no longer worth
worth living.
But these are not
those situations where
doctors feel obliged
to assist a patient to
end his life, do you understand?

And there are people too, neurologists who treat neurological
diseases of slow development that would not be willing to collaborate,
to respond positively to the request of a patient who still has two
years to live. . .

But. . .
I do not
wish to hide the fact that,
compared to "end-of-life," which you could imagine
to extend over quite a long time, it
limits the meaning to a period
when death, without
being in the next few weeks,
is still
inevitable and imminent,
which is contained in the notion
of "terminal phase"
and not "terminal illness." . . .

Robert
(Yves): . . .
in jurisdictions where we
have legislated on
these matters, including Belgium,
the lack of precision about the meaning of "terminally ill" and when
death is imminent has been the source of some abuses. . . . From the
outset, it
excludes assisted suicide . . . and it
also excludes situations
where a patient would
make an application at
an early stage when a diagnosis
of a
disease potentially causing
inevitable death
could make such a request.
So for us, it
cannot be early,
it cannot be
preventative, it
cannot be someone who
just had a diagnosis of
Alzheimer's . . .
it must be truly
in last
slice of life in
the final phase of the
life . . .
It is only at this limit
when you
might consider,
from a medical point of view, help
to die, considering that
the patient's suffering and inevitable death
counterbalances the burden of becoming actively
involved.

Ms.
Marchand (Michele): We
think we have to start
somewhere. And for us,
the terminal
phase is a way to start
somewhere in a limited way.
For us it is a
way to start. Studies show,
in countries where it
has been liberalized,
most successful applications
are patients really
in this phase ...
whose death is really
inevitable and imminent.

I
would not say that there will
not be other cases where
it might be debatable
whether this is an
appropriate treatment.
It is clear that there
are other cases, such as a
quadriplegic, or a disease
that, without being terminal or making death imminent,
brings very great suffering.
I think it is true that we
could think of
situations in which it would
still ... one could argue
that it would be an appropriate
treatment. But we
think that if we
start somewhere, we must
begin with [terminal phase] cases.
In any event, it
these are the cases
that doctors have asked
us to target,
because they are problematic
in clinical reality.

In
fact, it is indeed
euthanasia, but it should be understood
that the concept of physician
assisted dying goes a
little further. In euthanasia,
it could be a third party who
decides on behalf of the
patient, what [the patient wishes]. That is not the case at all in the context of
euthanasia on request.
An application must be made.

This is a necessary,
but not sufficient for
medical help to die.
This reuires something more:
it requires medical judgment of the medical conditions that
should be part of a continuum
of care, especially with respect to the additional conditions: the
terminal phase of
an incurable, fatal disease
and the presence of refractory pain.
. .
So it is necessary that the
patient
make the application,
and therefore it is
something very
limited and not
the slaughter that
is being forecast by many.

Ms.
Marchand (Michele):
It is not an euphemism,
huh? We do mean to say that it is an active
act with the intention of causing death. But
what medical aid to die means,
and what euthanasie does not mean,
is that it
is a medical procedure.
So this is necessarily
done by a doctor, unlike
euthanasia, which
can be done by another
person. It [euthanasia] can be an
act ... for which another person can take responsibility.
We think doctors
must assume
that responsibility and
they must do so
completely and that's why
it excludes
physician-assisted suicide. Because we believe that
physicians, if they assume responsibility, will not
give a
lethal drug to [someone] to put
in his drawer.
We do not usually do that, usually,
this is not how we
act. If we
decide to
participate in this act, we will
participate properly,
not [just providing] a lethal
drug, but assuming
the moral burden of performing
the act. And
for sure 3:29 that, for us,
"medical help to die," we
did not consider
at first. The term is not
used to create a euphemism. We thought it was more
consistent with what we want to
establish in practice.

. . . we think that, when medical conditions are quite restrictive,
even if a patient ... even for an incompetent patient, it could be
possible because the conditions are just as restrictive. So when a
patient is demented, if [an application] is made in a phase where death
is inevitable, even he is demented, and is suffering, why not, why
not? And that's the basis of our judgment. But here we must be sure we
are not in a period of early dementia, we must be sure that death is
inevitable.

And that's why the end of life is a little broader concept to include
the time when we think, here, here, we will intervene because it is an
end of an extremely difficult life, and everyone thinks the patient is
competent or incompetent. . . .
I do not think we should
open this up to incompetent
patients here and now, but
... there are people who
are in the same difficult
situations and who are incompetent.
What do we do?
Especially if we deny the use of
advance directives, deny substituted
consent, it means
that there will be people who are in extreme conditions at the end of life
where death is inevitable,
and will be suffering,
and we cannot do anything. . .

Ms.
Proulx: Thank you,
Mr. President.
Hello, Dr.
Bernard, I have
a quick question, then
finishing. We
often hear some doctors
who oppose this and
who quote the Hippocratic Oath. I would like your view on this. . .

a) Bernard (Charles): Yes.
There is conscientious objection,
huh, so therefore it is in
the bill now,
that the doctor may withdraw for religious beliefs,
beliefs ... Listen,
in the medical profession,
there are all kinds of people, just as in society,
so we cannot
unanimous. So it
is certain that there will be
a number of people
who will not do this.

b) I
do not know if you remember,
at the beginning of
interruptions of pregnancy, on
abortions, not all doctors
agreed on that question. ,
but I do not think Quebec
would not have the advantages
if it had declined
[to provide abortions] because there were some
doctors who withdrew from
that debate. So,
I think, without being the
same debate here,
we could apply the same parallel.
If there are some doctors
who have conscientious
objections, they will be able to
live or
perform without a problem.
So then, no, I
do not think there is
a problem with our code of ethics because, on the contrary, [medical aid
in dying] will be
included in health care, in patient care.

. . .
I would like to take up the issue of conscientious
objection. It
is a theoretical concept,
but when it
happens in practice,
the concept will
perhaps be a little more
difficult to apply. If
I understand correctly, you
agree that doctors may
simply refuse to participate
in physician-assisted dying,
the whole issue equally [applying] to
providing terminal care.

Bernard (Charles): ... on conscientious objection what is
interesting in this bill
-
I congratulate those who
have drafted it -
is that the
responsibility certainly lies on the doctor who [has the objection]. But
if he objects, he can
refer [the matter] to the institution, which
will be responsible
for finding [a willing physician]. Because
if you have a
conscientious objection and
it is you who must
undertake to find someone
who will do it, at this
time, your
conscientious objection is [nullified]. It is as
if you did it anyway.
I do not know if you
know what I mean.
So, the fact [that we can go]
to the institution where
there will be a committee or
a committee of the CPDP,
which will be responsible for finding the resources to do
the assessment and accept the request, [from our point of view], we like it a lot.
So Dr.
Marchand.

Ms.
Marchand (Michele):
This is because already
in the code of ethics,
there is an obligation to
transfer, right? We
may refuse for
moral or religious reasons,
but there is an obligation to
transfer. But
it is conceivable that,
when implementing a practice like this early on,
the transfer will be difficult.
So I think it's
a good idea to make
it the collective responsibility
of physicians and facilities
to make this possible,
so that the patient
ultimately is not deprived
of a service that should be
accessible.

Mr.
Bolduc (Jean-Talon):
. . . when you get to
practice in areas where
there is
a smaller populations,
although it is easy to
say: If it is not one
doctor, it will be
another. But the
other, he may have
the same problem. They spoke
of DSP, we spoke
of the CPDP, we talked about
the establishment, but
in the end - and
that's a point of discussion,
I do not have an answer
today -
in the end, if
we find ourselves in places
where
death is relatively
imminent and
there is nobody in
the medical team who can
perform these tasks,
will this not undermine the
right of the patient or prevent the person who has a
conscientious objection, from acting on his conscientious
objection? This is a question
we'll have [to face]. Then, I want to
tell you, in the
clause by clause study, we must
answer that. Because it
is easy to shovel
it onto 'the
health care system,' but at some point, in practical cases, it is the
law that causes it to be done poorly or done well. . . .

Ms.
Daneault: . . .being a doctor
... I think,
in the medical profession, we are more comfortable,
actually, with
"end-stage"
versus "end-of-life." . . . but I'd like you to
clarify what
you see distinction
between the
terminal and the end of
life. Because
that's the real question.

Ms.
Marchand (Michele):
The final phase
is when death is
imminent and more or less
inevitable. That is
the case, the difference, I
think, is the inevitability.
It is certain that death is
inevitable for everyone, eh?
Everyone will say:
Well no, it does
not make any sense to
bring this concept
in here, because death is inevitable
for everyone.
But we know for example
that a slowly
progressive disease,
a slowly progressive
degenerative disease, death is not
inevitable, ...
it becomes inevitable. . .

Ms.
Marchand (Michele)
... because it
is a serious and
terminal illness. [The patient] may be
in a critical state
... at an advanced stage,
but death is not
. . . They
want to die,
because of their quality of life
... then they are
suffering, there
is no denying
that they are suffering.
But death is neither
imminent nor
inevitable if we do
not help them to commit
suicide, to a certain extent.

Note:
The following translation is the product of a first run through Google Translate. In most cases it is
sufficient to identify statements of interest, but more careful translation is
required to properly understand the text. Translation block numbers (T#)
have been assigned by the Project as references to facilitate analysis and
discussion.

Thank
you, Mr. President. So, Mr. President, Madam Minister, Mrs, Mr. parliamentarians, while the
College of Physicians of Quebec thank you for allowing
him to present his thoughts on Bill No. 52 on the end-of-life, and I would add that we are honored to be the first to
audition before the Committee on this day
parliamentary session, so we
thank you.

So
this bill is, in
our view, a very important milestone
in thinking about life care,
and, in our
opinion, should be adopted.
Began in May 2006 at
our annual general meeting,
the discussion turned
into a broad public
debate, the end of which
the Special Committee on
Dying with Dignity are
handed over
in March 2012. From the
outset, please allow
us to recognize the
outstanding work done
on this topic extremely
complex and sensitive by
all parliamentarians, particularly
yours, Madam
Minister, you have
demonstrated compliance, quality
listening, rigor
and an understanding of the challenges
of a rare quality,
and we sincerely thank you,
it deserves to be
highlighted.

I
am accompanied today by
Dr. Yves
Robert, on my right,
who is the secretary of the
order, the doctor best known
in Quebec, and
Dr. Michele
Marchand, who is
secretary of the Working
Group in Clinical
Ethics college, which
... both have
coordinated the college
on this subject in recent
years. With the help of
guests, experts, representatives of
other colleges, the college
has developed positions
that were adopted unanimously
by the members of their
Board of Directors.

First, I will make
some general comments.
The College of Physicians readily
supports this bill
come quite
the prospect that we
initially proposing,
namely to address the
care of life as a
whole, to recognize
the patient's
legitimate right to express their wishes
about the care they
would like at the end of
life, to emphasize
the fact that this is more
appropriate when the
result of a dialogue
between the patient, their
families and caregivers,
to put the question
euthanasia in a
care perspective, which
allows to introduce a
relatively new concept, medical
help to die,
to define social and
medical criteria restricting
to exceptional situations
the use of this aid,
and keep account
the need to protect the most
vulnerable people to provide
a control mechanism that, in
addition to ensuring compliance with the
new legislation should allow
the collection of data that
is sorely lacking on
the end-of-life,
and ensure the continuation
of the debate that
this bill can
only be a step.

To
have been able to reconcile
these goals is in itself
a feat. Arrive
at a bill that
reflects the social consensus
while respecting the logic of
care and prevailing logic
in terms of rights and
freedoms, was a challenge.

So,
in its current form,
the bill already
has several important
qualities. First, the
perspective. The very title
of the bill gives
an inclusive perspective.
We can not stress
the need for all other
aspects of the project are in
this perspective.
If there is an item that
should be unanimous,
this is it, that
every Quebecer will
have not only the right
but access to the most appropriate care at the end
of
life.

On
the recognition of the role
of the patient and his or her
rights, the
bill for
second objective to recognize
the primacy of the will
of care clearly and freely
expressed by an individual, among others,
in advance directives.
In our opinion,
this is already the subject of a
broad consensus in Quebec,
but the bill goes a
step further to amend certain
provisions of the Civil Code,
in particular Article 4
to 7 and Articles 59 to
61. Also,
it is important to raise
a first ambiguity.
Even when we are willing to
recognize the primacy of the
will, there are other
elements that are essential
for decision making in
clinical practice: the
medical judgment, the other
stakeholders of the
healthcare team and sometimes
the relatives.
This is especially true
when it comes to
extreme and exceptional
medical care as
to where
die then
adds another crucial
constraint using
the limits that society
has decided to impose all
these actors and are
precisely the subject of this
debate this morning.

a) On
the provisions relating to the organization
of care at the end
of life, these provisions
require institutions to
provide for the supply of
end of life care
in terms of medical services.
Responsible institutions
in the management of requests
for medical assistance to die
particular seems
an interesting way to meet
both the demands
expressed by some patients,
the right to some doctors
to conscientious
objection and the constraints
based social
consensus.

b) Regarding the
creation of the
commission on end-of-life,
in our opinion, this is
a major element of the
bill and an extremely
structuring innovation.
This commission could fill
several roles, including the
monitoring, vigilance, research
and expertise,
but we will.

c) Despite these
qualities, we can not
ask the bill
to resolve all the issues
at once. For
example by limiting medical assistance
to die only to
able-bodied adults,
excluding those
responding to other medical
conditions, but which would become
unfit or
have been.
Even advance directives
written by a person while
she was fit and
that the
bill would give more
importance would not give
him access to this new
option, hence the
importance of this commission
could provide food for
thought in unfinished
areas.

d) We understand the
desire to respect the
social consensus carefully
identified by the Special
Committee requires making
careful choices.
And the college welcomes the
wisdom of such an approach
fortunately offset by
the possibility of further
discussion.

a)
Among the open questions,
note that the report of
the Special Committee on
Dying, in its Recommendation No. 24, encouraged the college to explore the possibility
that a person with
dementia caused by
degenerative brain disease
could make
an early application for
medical assistance to
die. It was hoped that a joint committee
of experts under the auspices
of the college would produce an opinion on this issue.

b) So it is with pleasure,
Mr. President, I join
our memory
... you received
the result of this reflection
conducted during the past
year by the Barreau du
Québec, the Quebec
Chamber of Notaries ,
the order of nurses
in Quebec and the
College of Social Workers and
Marriage and Family Therapists
of Quebec, as well as
several other experts.

c) All these professional bodies,
including the College,
have adopted this opinion,
and we will submit it
for the rest of your work,
and possibly those
of the new commission created
to address unresolved issues.

Some more detailed comments
now. On articles
1-3, the object
of the law and general provisions
in this chapter,
we wish to comment on the
definition of end-of-life
proposed in the third
paragraph of Article 3,
to be precise.
"For the purposes of this Act
- the
article reads like this -
for the purposes of this Act,
the term end-of-life
palliative care for people
in later life, including
terminal palliative sedation
as well that
physician-assisted dying.
"

So,
despite the extreme
importance that took
palliative care in
this difficult time that is the
end of life, it is not
clear to us that we should
associate too closely
end-of-life and
palliative care .
Palliative care is not
confined to the
end-of-life, any more than the
end-of-life
palliative care is limited.
The thing is even less
clear if we think
in these treatments
include a new option
such as medical aid
to die.
Palliative care has
developed in a context where
any action to actively
and voluntarily shorten
life was struck by a
prohibited. If
that is the
support that was
privileged and other routes
that
have been explored to relieve
symptoms, including
palliative sedation for refractory
symptoms. It is therefore
understandable that, for
many, physician assisted
dying is contrary to
the spirit of palliative care.
Also,
it would seem preferable to exclude any reference here to palliative
care and refer simply to "end-of-life"
all the care actually provided for this period when life comes to an end.

If we
want to introduce the
terminal and medical
assistance to die in this set
sedation, it would be
useful to clarify against
by the period
end of life usually
has several phases.
Speaking of the
terminal, it
just refers to when
the death of a person
is more or less
inevitable and imminent, even
if accurate
prognosis is
difficult to establish. But
from that moment,
we feel that the balance
between fear of
shortening life and the desire to
relieve refractory
symptoms can
easily switch in favor
of the latter.

It
also seems useful to
better clarify in this
section or elsewhere in the
bill, what is meant
by the medical assisted dying.
We have already expressed
elsewhere, this
term suits us because
it says it is
an act which is
done by a doctor in a
care setting, which excludes
physician-assisted suicide.
It remains
that this is an act of
intentionally causing
the death of a person,
but that,
in the context of end of life
care in exceptional
circumstances and under the
conditions established
by law.

Concerning Articles 8 to 24
relating to the organization
of end-of-life
issues when
placed in the context of a
range of end-of-life, it
actually becomes possible
to frame by
the general provisions of Act
s health services and
social services, regulations
and make appropriate links
with the Civil Code of
Quebec aspects
relating to consent to treatment.

Thus
the public health system,
either directly or indirectly by
formal agreements,
is the body responsible for
the availability, quality
and management
of the delivery
of care. Except for
home care is
provided by physicians
practicing exclusively in
office, structural elements
planned for the bill
appear to us quite
comprehensive and appropriate.
So these elements
is:

The
need for healthcare facilities
to develop a policy,
plan of organization and
a code of ethics for
end of life care.
Incidentally, we
welcome the commitment to book a
private person
in end of life
care room.

The
requirement for institutions
to produce periodic reports and
an annual report on all
activities surrounding the
end of life care,
including in particular the
terminal palliative sedation
and physician-assisted dying,
and report all claims,
even those that have been
denied. In this respect,
we would like to be
avoided administrative duplication.
We believe that information
should be collected at
this ... are
collected at this level
... should be
... could be
associated with the death
certificate and transmitted
to the Commission on the
end-of-life.

As for
end-of-life care
at home, the bill
provides for compulsory
affiliation of the physician and
the treatment team in
a health and
liability to obligations.
We note and
welcome the attention
given specifically
to the provision of terminal
sedation and medical
assistance to die and
more stringent obligations
associated with them.
However, this appears
difficult to apply in the
case of a doctor practicing
exclusively in the office
and on which the
CPDP establishment
we have no jurisdiction.
It seems to us that, despite
its attachment to an
institution regarding
end of life care, supervision
of the exercise of the
physician always
falls the responsibility of
the College of Physicians.

And
finally, the bill
provides for the duties and
powers to the Minister to
give directions,
ensure the implementation of
services, conduct surveillance
practices and intervene
to ensure the quality and
safety of services.

Good.
An article that
I really want to give
feedback, it is the
Commission end of life
care. So
I jump several stages
of my report. You
and I
hope you have read or
will read -
to say: Regarding
Articles 35 to 50 ...
42 Commission on
End of Life Care
as we mentioned earlier,
the creation of the
Commission on end of Life
care is an essential tool
and a particularly
welcome development not only
to ensure compliance with the
law, but also and especially
to provide a framework for
further reflection.
In this respect,
the research component
under Article 40 will be
crucial and
should be taken into account
by policy makers. The
creation of this committee
is in need
of a
responsible body of
essential watchdog
to monitor the application of
the law and able to
support the evolution of
practices.

In our
view, the main virtue of
this commission is to allow
the collection of currently
sorely missing
on the
end-of-life
data. Also, we believe
that all information on
end-of life
gathered in accordance with
Article 10 of the bill
should be sent to
the commission. The
analysis of such data is
essential in order to
eliminate hiding,
identify problems persist,
detect abuses and
intervene, if necessary.

We
also welcome the proposal by the
legislature as to the
composition of the Commission,
in particular by including a
user. And we assure
you that as a
professional order
concerned primarily we
will work closely with the work
of the commission.

Then
I'll go straight to the
conclusion, Mr.
President, as you wish
ardently. So I
would have liked to talk to
you ... but it's going to
go. The
conclusion. The conclusion,
wait a bit,
because there,
you make me skip steps
there. Conclusion.
In presenting this paper
today and the report
of the Working Group on
extended medical assistance
to die in people
with dementia,
the College of Physicians is pleased to
publicly expose the
many reasons why he
supports the adoption Bill
No. 52.
You will also
find in this paper
some proposals to
improve the bill.

And
if I do a short summary,
and I hurry, Mr.
President, the College of Physicians of Quebec
shares the main objective of
this bill is
to ensure that end-of-life
care to
most Relevant possible.
It is in this perspective
that also supports the
development of palliative care, a
certain openness to new
options such as medical
aid to die.

However, the position of the college
has always been clear.
The medical assisted dying
is not necessarily contrary
to medical ethics, but it should
remain an option of last
resort for situations
end exceptionally difficult
life. Among the
elements that justify
recourse there,
we should, we believe, find
that the person is
not only the end of life,
but in the final
stages of a serious and incurable
disease refractory
inflicting suffering.

Unfortunately, any
opening that
incompetent patients may benefit from the
medical to die
fears drifts
help. While understanding
that the legislature must be
careful, we can,
we believe, imagine
alternatives to completely close
the door to incompetent
patients, but those who have
led the
advance directives when they
were able.
..

Finally, the college also endorsed
the project's second objective,
namely to ensure the primacy
to the will expressed by the
people in respect of
care. The idea that
care is most appropriate
when the result of a
dialogue between the patient
and stakeholder consensus
is now, and we
adhere to.

However, we must avoid giving the impression
that all the wishes expressed
will necessarily be met.
Even when we are willing to
recognize the primacy of the
will, the fact remains that
other elements are essential
in decision making in
clinical practice, the
first medical judgment,
the other players in the
health care team and
sometimes that relatives.
This is even more
true that it is extreme and
exceptional care,
as I said earlier,
such as medical die
when then
adds another crucial
constraint that
limits the company
using decided
to impose all these actors
who are
precisely the subject of
this debate.

As
many
questions remain, the College
believes that the main virtue
of the bill is still
to ensure the continuation of
the reflection through
the Commission on End of Life
Care.
Established to ensure compliance with
the law, the commission
should also allow
the collection of essential
information for further discussion.
Hoping that the results of
our thinking will contribute
significantly to fuel
yours, ladies and gentlemen
Members, thank you for
allowing us to speak on this
subject. So,
we welcome
your questions.

The
Chairman (Mr. Bergman):
Thank you, Dr. Bernard
for your presentation, and
now, for exchange with
members of the commission,
and for the government,
a period of 21 minutes,
the official opposition, 19
minutes, and the
second opposition group, five
minutes. Madam Minister.

Ms.
Hivon Thank you.
From the outset, before starting
our return, I
want to stress ...
I was told that I
failed to mention, and it is
still relevant to
the people of the College of
Physicians, the presence among us
of another
ministry team, therefore
the general direction of
health and academic medicine,
with our new Deputy Minister
in this direction, Dr.
Louis Couture and
also the director,
therefore, academics
hospital Services, Dr.
Dufresne, and the team
. So, thank you
also for being here.
Thank you to the
College of Physicians for a
very good memory
of course, and
also for producing this
report so
that was a duty that
you were asked very nicely,
but by
the Special Committee on
Dying with Dignity and
which you are
compelled still very
fast, and I
sincerely thank you for all
the work and lighting,
as well as your memory and
this report can help us
achieve.

I want
to thank you too,
Colleague doctors,
because you have really
been a very instance,
very important in this debate,
throughout the beginning of
this debate in Quebec
when you filed this
report therefore in
autumn 2009 which also
led to the creation,
which was one of the factors
that led to the creation of
the special commission
where you really
came up with the concept
of appropriate end-of-life
continuum of care,
and is a concept that
I think we
really brought
the good
ground on the right
logic, which is really the
logical person
to consider the end of life
in all its complexity,
and to see some
limitations that could be
those in which both patients
and caregivers faced
in the current framework,
and this idea was truly
carrier, at
least for the work of the
committee and
this bill. So I
want to thank you and
thank you again for the role
you agree to play
today.

I
have many questions, of course.
Maybe two, from
the outset, two small
items. When you talk about
the definition ... it
is still important,
it gives
the definition of
end of life care.
I just want to say that
physician assisted dying is
not part of palliative care
when the definition is
exposed. So,
the end-of-life,
hospice and palliative care,
including palliative
terminal sedation
which is recognized by the people of
palliative care as a
palliative care and
medical assistance to die, which
is considered a end of life
care, but
we do not put in all
palliative care, so
that distinction seemed to us
important.

048

When you say
we should maybe
just talk about end of life
care, the idea
behind the definition
is that there
is really to emphasize the
concept of palliative care.
This is the first time this
concept then
appears specifically
in legislation in
a bill, it is
dedicated, there are
rights that are
also related to the
recognition, therefore,
the concept of palliative
care. So from our side,
it seemed to us very
important that the concept of palliative
care is explicit,
and otherwise care
... he obviously it
is not there because you're
dying you have
not have access to any other
type of care to which
you may be entitled and which
are provided
in the rest of the
legislative body.
But the idea of â€‹â€‹this bill
there, obviously it
is to provide the rights,
care for people in later life.
So I wanted maybe you
can clarify
this I would be interested
to hear from you whether
your position
still takes into account the
fact that obviously
does not exclude the
care, other
care of any kind
that a person obtainable.
First ...

Bernard (Charles): In the
section ...
a section that I
skipped, then
you will read, there were
still comments on
palliative care. But maybe,
if you allow me, I
will invite Dr. Robert
to clarify our thinking
on the distinction of the
college we wanted to do
or make between
palliative care and end of
life and why we want
to make that distinction
.

Robert
(Yves): Actually, the important
thing is to distinguish the
concept of palliative
care of a notion of a
structure. We often hear
of palliative
care. Palliative care can
be offered by any doctor
in any structure.
That is something that
seems very important.
This does not mean that
the structures would be
useful in some settings,
but it can provide
home care, for example,
with a doctor. It
is already being currently
palliative care
that nature must be
recognized. So our
concern is to avoid confusion
in terms
between the notion of
end-of-life, and I'm glad to hear
you make the distinction
between palliative care, palliative
and terminal sedation
medical help to die for
you ...
I understand that
you put a little bit
outside of the concept of
palliative care.

Ms.
Hivon: Yes. And
obviously ... which
is provided in the bill
is really palliative and
not the structure,
so we share the same
vision on
it. It's not
because you're not
in a dedicated palliative
care bed that means
you do not receive
good palliative care.

Ms.
Marchand (Michele): This is
because much of the debate
has focused ...
targeted the fact that it was
difficult to introduce in
palliative care, as currently
designed, using
medical die
would be contrary to the
spirit of palliative care,
and we think it
is not that the issue of
debate. What we want
is that physician assisted
dying is part of all
end-of-life
and not necessarily what was
previously defined
as palliative care.
And another
difference, too, is
that there is,
in the end-of-life
care there
are curative intent,
there in the end-of-life
and are not palliative
care. So I think that
the definition as it
is questionable in
relation to these two
elements there.

Ms.
Hivon: So just
tell you that this is the
definition for the purposes of
this bill because
there is
end of life, and
we know that palliative
care can not
exist in the context of
end of life also,
which can coexist with
the healing, and I remember,
the bill is
really for this
stage of life that is the
end of life. So,
always from the
perspective of analysis here.
And you are right to
say, medical help
to die, it was
quite our willingness
to consider a care
end of life, but
not as a palliative
care.

Regarding the issue of
idea of â€‹â€‹"terminal"
you want ... you want
to add, I must tell you that
it's the questions that are
already asked and
I've researched, there
researched, and
there is not
at all ...
there is no consensus
as to what a
terminally ill from
what I understand,
it varies depending on the
disease, it varies
contexts. I read
things that
we talked about two months,
six months, two years in
other parts of literature,
so I said to myself:
Is it really a fixed
concept, never mind
diseases where
everyone will agree
and that is ...
that will really add to
the notion of "end of life"
which in itself
is already really quite
explicit?

Robert
(Yves): There is
one important thing is that
... in our minds,
at least at the outset, we had the
idea and
wanted to convey this
concept then,
we could consider it
is medically when death
was imminent. It has often
been asked the question:
How much time?
There are states that
have decided to set
deadlines as six
months, three months, two
months. We do not want
to enter a fixed period,
but it was the general
feeling that a caregiver
who sees a person who is
in the end of
his life and where death is
relatively imminent,
we wanted to identify
it to
this level .

We
have had feedback from our
psychiatric colleagues where
there some mental illnesses
that could meet the
definition that is currently in
the bill and
why death
is not necessarily imminent.
And this is where
we wanted to avoid any
ambiguity, it was
really when death is
imminent, so terminally ill
- I
do not have a better term
- we wanted to
focus the issue of
physician-assisted dying
to exclude other pathologies
whose evolution is much
longer, but
that could lead to some
degradation and some
suffering, whether physical or
psychological.

Ms.
Marchand (Michele): Yes, I think we
have found no better
expression or better concept
than the
terminally ill ...
(its failure)
... in the terminal phase,
it is more or less
imminent, but what
we are saying is do
not mean to put a
precise prognosis
- 0-6 months,
0-3 months -
and death is inevitable.
What psychiatrists we
have noted, is that there
are people for whom
death is inevitable and
imminent because they
decided they wanted to die,
because they feel that their
life is no longer worth
worth living.
But these are not
those situations where
doctors feel obliged
to assist a patient to
end his life, do you understand?

And
there are people too,
neurologists who treat
neurological diseases of slow
development that would not be
willing to collaborate,
to respond positively to the
request of a patient
who still has two
years to live. Do you understand,
this is not the kind of
situation where doctors
are willing to say:
Yes, I think that death is
inevitable. It is more
or less imminent.
You suffer, and,
anyway, death will settle, so
we're ready at this
time to
help you.

But
it limits ...
I do not
wanna hide the fact that,
compared to end-of-life,
as you can imagine
quite a long time, it
limits the opening at a time
when death without
being in the coming weeks,
is still
inevitable and imminent,
which is contained in the notion
of terminal
and not a terminal illness.
It does not require that
it be necessarily
a fatal disease,
but it requires that
the evolution of the disease is
not advanced
enough because it
is degraded, but because
death is inevitable.
And we think it
is those conditions
that doctors are willing to
justify themselves
an intervention,
collaboration act.

Mme Vallée: Thank you.
So at first, I
want to thank you.
Your memory
was extremely interesting,
and then, for those who, like me,
have not participated in
any discussion
surrounding the
filing of the report of the
Special Committee
Dying with dignity, you have done
a very important job.
And I tell you:
I would like to continue
a little bit because
I also have a lot of
questions.

So I
would like to continue a
little bit of thinking
about the question of the
definition because,
for me, is to use the
right words, and
precise terms, c
is the
first key to the
social acceptability of the
bill, what can be
... Often, people
do not understand,
misunderstand what we are trying
to explain the
bill. So if
words, if the definitions
are clear, in my opinion,
we will be able to explain
where we want to go.
And the debate that surrounds
the whole question of including
the final phase in
the conditions,
also, medical assisted dying,
conditions that will
move forward with medical
assistance to die is also an
element very, very
important.

In
your discussions with
ministers, Dr.
Marchand, you mentioned that
the definition of article 3
... the third paragraph of
Article 3 was somewhat
... was poor,
and I was wondering if you
had a formulation,
suggested wording that better reflects
the spirit of the law that
you had when you read
the bill.

Ms.
Marchand (Michele): I think it
is best not to
dwell too long.
I do not have a
formulation. But I think
that ... we
think "just"
going with
"including" and I
think there was
one ... at least
for me in
my reading ... Well,
but I think we should not
... In any case, I
do not have a formulation
that could be discussed
quickly there.

Robert
(Yves): Yes.
Emphasize that,
in jurisdictions where we
have legislated on
these matters, including Belgium,
the lack of precision that
is terminally ill and
when death is imminent
has been
the source of some
drifts. And so
have ...
In any case, it is
clear in our minds since 2009,
when we went out
the first time on that
subject, in our mind,
it is really limited to
that. It
excluded immediately
assisted suicide
- we have
always said, we repeat
today - and it
also excludes situations
where a patient would
make an application at
an early stage when a diagnosis
of a potentially
disease causing
inevitable death
could make such a request.
So for us, it
can not be early,
it can not be
preventative, it
can not be someone who
just had a diagnosis of
Alzheimer's to say something,
it must be truly
in last
slice of life in
the final phase of the
life of that person where
medical help to die,
having been
made â€‹â€‹directly or indirectly
- and you will see
with advance directives
- may be considered.
It is only in this limit
then you
might consider,
from a medical point of view, help
to die, considering that
the patient's suffering,
the inevitable death
counterbalance the weight
is to become actively
involved.

Mme Vallée: And I
understand that it would be to
help prevent, for example,
an individual who is
quadriplegic, which
... for example,
there has
terrible inner suffering,
may rely on the provisions
of the bill, for example.

Ms.
Marchand (Michele): We
think we have to start
somewhere. And for us,
the terminal
is a way to start
somewhere in a small space.
For us it is a
way to start. Studies show,
in countries where it
has been liberalized,
most successful applications
are patients really
in tune ...
whose death is really
inevitable and imminent.

I
would not say that there will
not be other cases where
it might be debatable
whether this is an
appropriate treatment.
It is clear that there
are other cases, as a
quadriplegic or a disease
without being ...
death, without imminent
brings very great suffering.
I think it is true that we
could think of
where it would
still ... one could argue
that this is an appropriate
treatment. But we
think that if we
start somewhere, we must
begin with those cases.
In any case, it is
the case
that doctors have asked
our target,
because it is those
that were problematic
in the clinical reality.

Mme Vallée: In your
comments on the whole
issue of accessibility
of palliative care, because there
is also that element
in the bill,
which is very important is
to allow all those
who need or wish to
seek such care then
to have access.
as an organization, how do you,
how do you see the
accessibility precisely
palliative care across the
country? Because it
is a challenge. You could
want, but
it is something that
is real? Are we
currently in the territory
of Quebec, access to
palliative care? And
if we're not there yet,
what we must
do in order to give
access to citizens of Quebec
to that service?

Robert (Yves): Actually, the
first thing is that
there will have a lot
of training, I feel,
at all levels,
to all stakeholders.
You'll have ... And I
think Bill is a great
opportunity to send a message
across the health care system
so that there is a
kind of -
excuse me the picture
there - a kind of
crystallization efforts
around a common project.
And the obligation
created institutions to
have a plan force,
to some extent,
the implementation of
such services. The biggest challenge
for me, it will be
home care, because in fact
means, through
surveys that are done in
the population, there
was a large proportion
of our citizens,
citizens who wish to
die home, while
in fact, the same
proportion then
currently dies in
health facilities.

I
think at the end of the line,
that's what is the message
that I understand,
and there could be,
depending on the region or in
the resource
model, in fact,
that will be suitable
for people locally.
I think it is a message of
listening to the needs of the
population that is launched.
At the operational level, it is sure
that there will need
resources that side,
a recovery
or a
prioritization of
those services in a particular way
in some places.
I think it is realistic
in the short term,
relatively to organize
it. There
will be, I
think the public is ready to
have those services
and I think the network is ready
to organize, to a certain
extent for the
offer.

Mme Vallée: I would
like to hear you and
maybe we can come back,
really the definition
of medical assistance to die
as such, because
in conversations I
have had some people
are questioning why
not call a spade a spade.
Why not use the
term "euthanasia"?
So I'd like to
hear from you on this issue,
because unlike my
colleagues here, I did
not participate in the work
of the commission.

In
fact, it is indeed
euthanasia, but it should be understood
that the concept of physician
assisted dying is a
little further. Euthanasia,
it could be a third party who
decides on behalf of the
patient, what is
his will. We are not
here at all in the context of
euthanasia on request.
An application must be made.

This is a necessary,
but not sufficient for
medical help to die.
it takes something else:
it takes a medical judgment,
it is
a medical condition and it
should be part of a continuum
of care, especially in these
conditions, and this is
added, which is
terminally ill with
an incurable disease,
and mortality
with refractory pain.
That is, medical conditions.
So it is necessary that the
patient may
make the application
and therefore it is
something very
small like
opening and not
the slaughter that
is announced by many.

Ms.
Marchand (Michele):
It is not an understatement,
huh? We vaeut
that it is an active
act that wants to bring
death. But
what it says,
then medical help
qu'euthanasie does not say,
then, is that it
is a medical procedure.
So this is necessarily
done by a doctor, unlike
euthanasia, which
can be done by another
person. it can be an
act ... one that
is responsible for it.
We think doctors
douivent assume
that responsibility and
they must do so
completely and that's why
it excludes the
physician-assisted suicide,
because we believe that
physicians, if they take
something they
will not
give a
lethal drug to me
that the guy is going to put
in his drawer.
We do not do that, usually,
this is not how we
are. If you
decide that
participates in this act
there, we will
participate properly,
not giving a lethal
drug, but assuming
the moral weight to perform
the act. And
for sure 3:
29 that, for us,
medical help to die, we
had not considered
at first. It was not
to create a euphemism,
we thought it was more
stuck to what we want to
establish a practice.

Ms.
Hivon: Thank you.
So I could not
have said better medical
assistance to die.
In fact, the difference,
it is based on two
elements. Is that the
request must come from the person
itself and essential
in a medical context with
the presence of the doctor.
So this is exactly what
explains the difference and
simply, perhaps to return to the
question, because it is
still important to define
the framework within which we
work. For us, the
concept was the most
promising, both in the
work of the commission
in the bill,
it was the notion of
"end of life" and,
for us, is
eloquent enough for a
doctor ,
to make a judgment.
Is it that we are in
a situation where it could
apply, or not?
Yes, because it
is the end of life,
not because
we are not the end of life.

Then,
I want to say,
when we talk about
the possibility of a
quadriplegic person is
already ruled there in
the bill, because it
must be
facing a serious and
incurable disease. A
person who is a
quadriplegic ...
she is in a state.
It is not a disease.
So now,
all that is excluded and
all the bill is
based on the end of
life. So
already, we exclude these situations, when death is not inevitable,
because we are talking of a serious and incurable disease, and therefore
it goes without saying that death will ensue and we in this period of
life when we are dying already, we
exclude those situations
where death is not inevitable,
because we are talking of a
serious and incurable disease
and so it
goes without saying that
death will ensue and
we are in this period
of life when one is
dying. And I think
we have the same concern, but
this is
the correct translation.

So that's it,
the challenge is
to say: We're
not dealing with someone
who has
10 years to live.
No, it's obvious,
if it has 10
years to live, it is not
the end of life under
the law, we are not
dealing with someone who has
a disability. No,
that's for sure,
this is not a serious and incurable
disease. So this is
how to define the
best without putting
time period,
because everyone told
us that we should not
set period of time,
and we too think
that we can not cut
it with a knife,
but the notion of "terminal"
leaves me still
puzzled as to whether
"terminal" for a person who
has cancer versus
"terminal" for someone who
has a degenerative disease,
we are faced with the same
reality. So I think we
have the same goal,
and then the idea
is to happen
to make it as clear as
possible for the physician.

So
you can comment, but
I have another very important
issue that I do not
want that ignores,
is the question of
incapacitated persons. So,
you just ask, in fact,
the opening is larger,
thus including
in the report that you
deposit today for the
people, so that could be
suffering from dementia
can ask
in advance to
that they can receive medical
help to die.
And I get this
very open, but I
want you to tell me
how are we going to
provide so precise
in advance directives
when they should
give rise to medical
assistance to die
and also
how will ensure that
all the conditions
laid down in Articles 26 and
following, namely
an insatiable
and intolerable
suffering, how
are we going to ensure
that if the person has,
therefore, a
dementia -
one thinks, for example,
Alzheimer's disease -
how are we going to
reconcile the requirements
and the state of incapacity
of the person?

Ms.
Marchand (Michele): I'll
start answering upside
there with dementia,
OK with
dementia. The
conclusion of this report,
there is that
dementia presents a
particular difficulty, but
are unsuitable
for all patients.
Dementia presents
a particular challenge
because the period is very long
between the fact that the
patient is fit then
it becomes completely
incapacitated. So
that's what makes the
application of advance
directives difficult.
And it is proven
in studies where it is
permitted by advance
directives, euthanasia, there in
... and it is allowed,
on the basis of dementia,
it does not happen,
because we do can not say
that the person is
expected, it is too far, the
change is too slow for
us to give effect to
advance directives. So it
is a problem for advance
directives, but it does not pose
an insoluble problem in
decision-making when a
patient is incapacitated
because there
can be appealed to the
substitute consent is
that, our logic there.

So,
even though ... So,
we can assume that
incompetent patients may have
the same conditions that give
access to medical assistance
to die and we
could take the decision on
the basis of either an
advance directive or
substituted consent, which
is particularly difficult for
advance directives - it's in
dementia -
but not
impossible for the
substituted dementia
or other form of
incapacity consent.
You understand a little
the idea here?

So it is not true that it is impossible to get out for all
incompetent patients. What makes us fear is involuntary euthanasia.
That's what we feared there. But we think that, when medical conditions
are quite restrictive, even if a patient ... even for an incompetent
patient, it could be possible because the conditions are just
restrictive. So the patient is insane, if it is made in a phase where
death is inevitable, even if it is denied and if the suffering, why not,
why not? And that's the basis of our judgment. But here we must be sure
we are not in a period of early dementia, we must be sure that death is
inevitable.

And that's why the end of life is a little broader concept to account
for the time when we think, here, here, we will intervene because it is
an end of life extremely difficult, and the patient is fit or unfit,
everyone thinks.
Do you understand a little
the idea here?
And that's why
we tried to restrict
a little, at the
medical criteria for
power just
in a second ...
I do not think we should
open up to incompetent
patients, then,
immediately,
there , but
... there are people who
are in the same difficult
situations and who are unfit.
What do we do?
Especially if you close
advance directives, we close
the substituted
consent, it means
that the people who will
be in conditions of
extreme end of life
where death is inevitable
and there
are going to be suffering,
we can not do anything,
there .

Robert (Yves): To answer
your second,
when are we going to
decide, in
the case of an incapacitated
person, what is proposed
in the report, you
will see, it is essentially
two mechanisms. The
first is that
the agent and the substituted
consent, but only
because we can not
understand very well,
as it is a final
decision, the burden of that
decision will be huge
for the agent. So we
added a second element
called prior authorization,
that is to say
that there is a judicial
or quasi-judicial body, it could be
a judge of the Commission on
End of Life Care
or something else
that could be
a priori and not
a posteriori, assistance and
sharing the burden
then with the agent,
in very specific situations,
which would check
the advance directive,
if the conditions are met
in order to consider
this final decision.

Ms.
Proulx: Thank you,
Mr. President.
Hello, Dr.
Bernard, I have
a quick question, then
finishing. We
often hear some doctors
who oppose and
who claim the Hippocratic
Oath. I would like your
view on this.
How you play
or how you position yourself
against that?

a) Bernard (Charles): Yes.
Was conscientious objection,
huh, so therefore in
the bill now,
the doctor may remove
it if, for religious beliefs,
beliefs ... listen,
in the medical profession,
there are all kinds of people
as in society,
then we can not
unanimous. So it
is sure that there will be
a number of people
who will not.

b) I
do not know if you remember,
at the beginning of
abortions, on
abortions, so it
is not all doctors
agreed on that question,
but I do not think Quebec
would not have the advantages
he had declined
because there were some
doctors who withdrew from
that debate. So,
I think, without being the
same debate here,
we could do the same parallel.
If there are some doctors
who have conscientious
objections, they will be able to
live or
perform smoothly.
So then, no, I
do not think there is
a problem with our code of ethics,
however, because it will be
included in health care
in patient care.

Mme Vallée: Thank you.
I just want to revisit the
issue of the definition of
physician-assisted dying.
Is it would not be
appropriate, given precisely
the distinction you made
so clearly between euthanasia
and the concept of medical
assistance to die,
to define it within the
bill or
a definition so
we really can,
as I said, there
that citizens can have
a benchmark when
will be no question of
physician assisted dying and
also to avoid
all discussions and
... really do
understand what medical
assistance to die?

Robert (Yves): Listen,
from a pedagogical standpoint, it
may be
included in place
of the law
to remove any ambiguity.
There will certainly be a big
time after a
possible adoption of the
bill, or at least
awareness of a
communication plan that
will have to send
to the people to explain
exactly what we are talking
about. There is a lot
of confusion in people's minds
between the refusal of
treatment, medical assistance to
die, palliative sedation.
That's all
you hear in terms
of public space and where
people give their
sometimes conflicting
definitions. I think it will
be necessary to create,
if you will, a
kind of communication plan
that will help restore
exactly what it is.

From
our side,
we have a duty to explain
to our own members,
what is done
intensively as possible,
and ...
but there will certainly
be public information
to, and this
should be a items included in
each plan palliative care
at each institution. When a
patient is going to bring
a parent or
yourself with
palliative care, we will have
that there is a form of
teaching to go and explain
those terms and options
that are possible. Moreover,
because we understand that
this bill there
is an opening to options.

And I understand that the
Special Committee
had heard it was a
desire to open
options. And I
think that's it,
I think he'll have to
rely on
belief, but also the respect
of fellow citizens
so that they can at least
express these options
there. And elsewhere,
in countries where they
have legislated not only
palliative care has not
decreased, but they were
better and more
expanded in all jurisdictions
where there has been
legislation in this sense
. Therefore, in
our opinion, it would be more, if
only to be able to open
the debate and
to discuss these issues
openly.

Mr.
Bolduc (Jean-Talon):
Thank you, Mr.
President. First, congratulations
on the quality of your
memory, and among others
the second part, as you said, dealing
with people who are
cognitively impaired. it will be
the discussions we will have
to have. Me
too, I had
discomfort when I read
the bill on the matter
at any time, and
the professional and the
patient or the person who
may have medical help
to die, could
not ask
concept of time.
I do not think we should
enshrine a specific
time. But I,
to my knowledge, since the
beginning of this discussion
is that we absolutely had to,
and that it is for
the terminally ill,
we may redefine
the term if
it is not correct,
but we did not want,
for example,
someone who suffers from a mental illness,
we will give an example,
Schizophrenia, which
inner suffering, and then
at the end he said:
I suffer so much.
I have a disease that one day
I will die, but not
this one. Why is it
that I could not
access the service medical
assistance to die?
The example also the
quadriplegic or
paraplegic who does not
accept his situation, which is
depression and at
one point, the
application also.
I do not see
how the law
will help
offer.

So
there was that
discussion we will have to
have properly.
And I agree
with the minister, we
probably have the same
goals. You just
find the right words,
because after this is
what's going to stay.
Then do
not forget also that there
are some who can use
that law to defend causes
that this is perhaps not
those where we
wanted to
be defended.
So that's the discussion we
will have to make.
I would like to take you
on the issue of conscientious
objection. It
has a theoretical concept,
but when it
will happen in practice,
there is
perhaps a little more
difficult to apply. If
I understand correctly, you
agree that doctors may
simply refuse to participate
in physician-assisted dying,
the whole issue also
provide terminal care.

Bernard (Charles): ...
on conscientious objection
is that what is
interesting in this bill
there and then ...
I congratulate those who
have made the writing
is that the
responsibility it is sure
that it is the doctor
who. But if he
objects, it can
refer to the institution
will be responsible
to find. Because
if you have a
conscientious objection and
it is we who must
make the
process of finding the person
who will do at this
time, our
conscientious objection no
longer applies. It is as
if we did anyway.
I do not know if you
know what I mean.
So the fact of going
to the institution where
there will be a committee or
a committee of the CPDP,
or responsibility to
that place will
find the resource to
the assessment and acceptance
of this request for
us, we like it a lot.
So Dr.
Marchand.

Ms.
Marchand (Michele):
This is because already
in the code of ethics,
there is an obligation to
transfer, right? We
may refuse for
moral or religious reasons,
but there is an obligation to
transfer. But
it is conceivable that,
when planting
is early
on a
practice like this,
the transfer will be difficult.
So I think it's
a good idea to make
a collective responsibility
of physicians and facilities
to make this possible,
so that the patient
ultimately is not deprived
of a service to be
accessible.

Mr.
Bolduc (Jean-Talon):
Quickly because I
would like my colleague
a question is ...
We'll have to discuss it
because, when you get to
practice in areas where
there is
a smaller populations,
although it is easy to
say: If it is not the
doctor, it will be
another. But the
other, he will have
the same problem. They spoke
of DSP, we spoke
of the CPDP, we talked about
the establishment, but
in the end - and
that's a point of discussion,
I do not have an answer
today -
in the end, if
we find ourselves in places
where is that
death is relatively
imminent and
there is nobody in
the medical team can
perform these tasks,
there is
what is undermining the
right of the patient or
is prevented person who has a
conscientious objection, he
realize his conscientious
objection? This is a question
we'll have it
... Then, I want to
tell you, in the
clause by clause, we must
answer that. Because it
is easy to shovel
it in the
health care system,
but at some point,
the case studies,
there is
a law that makes
it is done poorly
or done well.
Thank you, Mr. President.
I'll let my colleague
ask.

Ms.
Blais:
One minute. Listen, I felt,
in your memory,
there was something important,
the creation of the
Commission on End of Life
Care. I
have a feeling that this is
a guard, and it
would perhaps
have tags and also,
when the questions are coming,
then we could explore.
And I ask
the question more
specifically to Dr.
Marchand, who cares for
ethics, which raised
just now ...
I felt
the importance
far when there would be
cases, including
cases of consciousness or
if patients
wishing to avail themselves
of the law.

Ms.
Marchand (Michele): Okay.
I think that's
very innovative compared to
the control boards
that exist in countries where
there was
... where it
has been liberalized,
there. The
control boards are designed
to verify that it was done
in good conditions.
But it is sure that people
relate mainly
where they followed
the terms, eh?
it is there
that all other cases,
patients unfit, for example, minor
patients, requests
that have not been heard,
well, you lose,
and that is what
is calculated as drifts.
it is
that people continue to force
opiate because otherwise,
they will be forced to
declare as euthanasia
doses. it's that
there ...

Ms.
Marchand (Michele)
... that's why
it's interesting to collect
all the data
there to see, though, is
that there are incompetent
patients who are served by
the law or is it
that there are patients who
really were not terminally
ill and who should
have access, it
would have been proper care.
Here we will be able to
make adjustments from
a smaller opening,
we will perhaps be
able to see more clearly
because we have no data
yet.

Ms.
Daneault: Thank you,
Mr. President.
Thank you for your presence
and, indeed,
your great
memory. I go back to
the notion of incompetent
patients because it,
I totally
agree with you in the sense
that why someone who
is suffering from dementia,
but we know that
the disease can last up to
ten years, why not
allow it, when
you know it will reach
a terminal phase and
suffering, why, he would not have
access to health care
there?

And
the question I want to ask
you, because we know that in
a living will, a patient may
decide to refuse
cardiopulmonary resuscitation, is that
we could not include in
the law a little
the principle of living wills
even before ...
Because I
can tell you that if
one day I'm
suffering from dementia, I would like
to receive
care at the end of
life too. So
are we could not
believe that living wills
could include the fact
benefit from end-of-life,
even though at that time,
the person, the patient is no longer
incapacitated?

Robert (Yves): I
think this is precisely the
question asked on
more specific section
advance medical
directives. In fact,
our current understanding is
in the bill,
excluding the help ...
maybe it
was a mistake,
but it seems to
exclude medical assistance
to die and
advance medical
directives. So,
the question is not
so much a question: Does
it could speak in
a living will or advance
medical directive?
In our opinion, yes,
he might be able to express
it in there, the
challenge is to apply,
that is to say when
going on
and decide
what mechanism we give
to decide that these
guidelines will apply,
that's what is a little
difficult.

That's what I told Ms.
Hivon sometimes,
that is to say that
states ideally
have an agent, and possibly
another step with
prior authorization.
And that's what
allows us to ensure
event safeguards
to avoid abuses
because we can easily
understand that opponents of
the bill could
then invoke this provision
to people who are unable
to see it as a
threat vulnerable
to potential
customers.

Ms.
Daneault: Thank you.
We know, against,
among others, in the
case of dementia,
there are stages,
and we arrive at a
terminal stage,
went to stage
7, then, is that
we could not think
of the
mean squarely in
Bill that could
be included in the
background, in a
terminal phase of care
or end of life,
to include the 6-7
stage in dementia?

Ms.
Marchand (Michele):
What we are proposing,
rather than make specific
forecasts by disease
precisely there,
is that the same
conditions for access
to the
medical conditions that would
give them access,
refractory suffering,
serious disease and
end-stage or
advanced decay,
are the same that give
access to patients,
even if they are demented,
the demented patients,
as another incompetent
patient. But then
it is clear that advance directives,
it is more difficult,
because he has made
â€‹â€‹about seven, eight years before.
it's that,
then that's what
poses particular problems.
But we think this
is not an insoluble problem,
because there ...
if there is an agent,
then the
... we could use
the substitute consent,
then, not only
advance directive.
You understand a little
now?

Ms.
Daneault: I'll
obviously the notion of
terminal illness. Actually,
well, being a doctor
... Then I think,
in the medical profession, it
is more comfortable,
actually, with
"end-stage"
versus "end-of-life." in my
opinion ... I also
think it would be
clear to all, but I'd like you to
clarify what
you see distinction
between the
terminal and the end of
life. Because
that's the real question.

Ms.
Marchand (Michele):
The final phase
is when death is
imminent and more or less
inevitable. That is
the case, the difference, I
think, is the inevitability.
It is certain that death is
inevitable for everyone, eh?
Everyone will say:
Well no, it does
not make any sense to
bring this concept
there, because death is inevitable
for everyone.
But we know for example
that a slowly
progressive disease,
a slowly progressive
degenerative disease, death is not
inevitable in ...
it becomes inevitable.
Same thing for a patient
... If there are
psychiatric patients,
there is
the psychiatrists who
mainly reported
the problem we
...

Ms.
Marchand (Michele)
... because it
is a serious and
terminal illness. They may be
due state
... advanced,
but death is not
deprivation ... They
want to die,
because their quality of life
... then they are
suffering, there
is no denying
that they are suffering.
But death is neither
imminent nor
inevitable if we do
not help them to commit
suicide, to a certain extent.

Ms.
Daneault: Yes.
Thank you, Mr. President. Forgive
me for being late. Well, obviously,
I want to commend the
members of the government, members of
the opposition. And I'm very
happy to be with you
on this board.
Obviously, it is
still very sensitive
topic as for all
Quebecers. I can tell you
that in my riding
for a few months, it was
the subject of questions
vis-à-vis the
position we will take.
And I think the
committee is
to hear people,
to reassure the population,
because there is some fear
of course ... of
ignorance of the subject.
And I think the work that the
committee has
to do is
to hear all the memories
of everyone -
I think they are all
important - for ...
to better regulation.

By
cons, of course,
is ... And I continue
to say, I am pleased
to be part of this ...
this issue there,
which is a very sensitive
issue, but I think we
should, in 2013,
to send it to the
population in all respect and
of course the lack of
political partisanship. I
think it is for
the welfare of all
Quebecers. So
I am very pleased to welcome
all the members in this
committee. And I thank them
in advance for their
participation.

The
Chairman (Mr. Bergman):
Thank you, honorable member.
Colleagues, I hang
for a few moments,
and I ask the representatives
of the Federation of General Practitioners of
Quebec to take
place at the table.